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[Aviva]

Human Rights Reader 38

PUTTING EQUITY AND HUMAN RIGHTS IN HEALTH ON THE AGENDA: THE ROLE OF NGOS.
(2)

Experiences from some NGOs  already using the Equity/Human Rights approach:

17. As far as international NGOs are concerned, CARE has probably advanced
the most in its efforts to operationalize the Equity/Human Rights
(E/HRs)-based approach. Since January 1999, they have had a (CARE) Human
Rights Initiative with a HQs coordinator and program advisor and a field
program assistant devoted full-time to the Initiative. They have been
raising awareness in most CARE country offices around the world, building
the capacity of their staff globally, ensuring that CARE's principles and
policies facilitate the HRs-based approach being progressively adopted, and
they have been forging strategic alliances with like-minded programs and
initiatives. They carry out training, research and pilot activities in HRs,
and they publish a quarterly newsletter ('Promoting Rights and
Responsibilities') featuring cases from the field, staff reflections,
conceptual pieces, a section called Window to the Wider World and a section
on worldwide new resources. They are about to publish a Rights-based
Training Manual and a set of Case Studies on CARE's Implementation of the
Rights-based Approach. Very helpful has been the compilation of a Frequently
Asked Questions About the Adoption of a Rights-based Approach document which
has been revised a few times. (More information to be had from Michael
Rewald at rewald at care.org)

18. Note: Equity and HRs do not feature explicitly in the charters of
international financial institutions (IFIs) and those of many donors
although most bilateral development agencies now give prominence (and mostly
lip service?) to both participation and the promotion of equity and human
rights.  Moreover, the commitments of national governments to respect,
protect and fulfill health as a right has yet to be properly reflected in
their policies and practice. The E/HRs-based approach demands that
government policies address ill-health and malnutrition 'to the maximum of
available resources' (including resources available through international
development  assistance). It is this what some NGOs are starting to make
governments accountable for. Finally, also note that a new publication of
WHO states that poorly designed and implemented current health programs and
policies can (and do) already violate HRs.

Practical ways for NGOs to adopt the Equity/Human Rights focus in their
health work:

19.The equity/human rights approach does not offer a panacea or magic bullet
that will see resources, services and power instantly transferred to the
poor and vulnerable. In part, this is due to the fact that the international
community has no practicable ways of imposing punishments or fines on
governments (or others) that violate or ignore their commitments to human
rights. On the other hand, NGOs have not used their potential to more
proactively seek government compliance in this area. There are proven
tactics that can be used --and these need to be shared more widely.

20.The main question at hand here for NGOs is: If current health programming
is mostly time-bound, donor-driven, and supposedly apolitical, how can they
pursue meaningful, long-term and rights-holders-driven transformations in
the sector based on challenging oppressive power relations?

21.Understanding how societies construct the system of inequities that
include inequities in health is the first step for NGOs to help people claim
their rights.

22.But understanding is not enough. The E/HRs-based approach insists on
behavioral changes of the NGOs professional staff themselves (to be seen as
a 'staff investment') rather than the latter simply starting more
'HRs-compatible' new programming; it insists that the E/HRs-based approach
entails a different concept of development programming that does not only
focus on the  methods of implementing new activities. Without behavioral
changes, staff will simply repackage what they are currently doing in an
'E/HRs-based approach language'.

23. When designing projects, a formal analysis of the rights being addressed
has to be done with the community; this includes understanding how aid can
compound some of the problems to be solved, as well as analyzing the
unintended consequences of the work to be undertaken. (Unintended impacts on
people's rights happen for three different reasons: a lack of knowledge
about the context in which NGOs work; a lack of thought about unintended
impacts of their interventions, and a failure to take responsible actions).

24.For all the above reasons, from now on, a growing part of NGO efforts
should focus on making governments accountable to meet their equity/human
rights obligations; and there are concrete steps that can be followed to do
this (see below). More and more, the root causes issue (i.e., taking a new
look at issues of power, control, ownership and sustainability) and the
rights violations actually found should become the main agenda for
discussions with authorities.

25.That is why calling for an NGO (re)organizational meeting (or retreat) on
these issues is now necessary. It is high time that people in NGOs find out
more about this equity/human rights-based approach to health and
particularly about how to operationalize it . This expertise is now badly
needed.

26.The real tough challenge NGOs face in these organizational meetings is in
translating what some feel are still vague principles into concrete plans
and actions --even if they find it difficult to alter power relations in the
short-term.

What does it take, then, to understand and adopt an E/HRs-based approach?:

27.To start from scratch and to familiarize NGO staff with this approach, a
one-day general introduction to HRs and the E/HRs-based approach, defining
its characteristics, is suggested; this is to be followed by a series of
meetings in which exercises are presented for staff to learn how to carry
out causal/ responsibility analyses and to identify the responsible actors
(duty bearers) at each level;  this is followed by exercises on how to
develop advocacy strategies to influence pertinent decisions an actions. A
final session should focus on identifying the NGOs strengths and weaknesses
to adopt the E/HRs-based approach and should conclude with delineating the
steps proposed to progressively implement this approach. At the end of the
training, each staff member should be asking him/herself: 'Am I really
committed to this?' ...and this should be discussed.

28.There is no shortcut or blueprint methodology to achieve a shared
understanding  of these concepts. NGOs must acknowledge that this is a time
consuming and intense process. What is clear though is that NGOs will
identify a host of new priorities.

29.What the addition of these priorities will mean for each NG, and what it
will lead to in the future, is also to be explored in these meetings.
Towards the end, each NGO should have a long-term vision for health --one
that adds the equity/human rights perspective. This should be ultimately
reflected in increased funding for activities that point to that vision
(funding needed for this is considered to be neither very substantial nor
very difficult to raise); it should also mean that NGOs will become more
vocal advocates for both health and human rights and better watchdogs of
human rights violations and of existing and emerging inequities in health.

30. Only after going through such a collective learning process will the NGO
's internal organizational systems, its processes, policies and
organizational culture change as needed. It is more, only when a critical
mass of people in the organization changes to think in the new way will the
NGO as a whole change. Each staff has relationships with people at many
levels of the organization; each should gradually work to influence them so
that more and more staff join by understanding and supporting the changes
called for.

31.After going through the training, the next challenge for NGOs becomes to
use the international human rights agreements, they now will be more
familiar with, practically:
-in the health policy making process (their own and the government's),
-to guarantee people's participation (beyond mere dialogue),
-to assess and analyze people's health and nutritional needs together with
them,
-to set commonly arrived at and agreed objectives,
-to, together with and/or backing claim-holders, place informed and
effective demands in front of authorities and demand for accountability, and
-to call for and get involved in networking and solidarity work.

32.Also after the training, NGOs will find themselves moving things
traditionally deemed unchangeable (e.g. the assumptions column in their
project logframes) into more explicit objectives of what they want to
achieve in their different projects. This will also mean that, later,
measuring the impact of their projects will also have to be from a HRs
perspective. (What is here meant is that NGOs have to honestly question what
they put in the assumptions and risks column of their project logframes and
ask themselves: Are these assumptions really out of their domain of
influence or control? Can something be done to proactively address them?).

33.Further, NGOs have to decide whether they start applying the E/HRs-based
approach in their current projects or rather wait for new projects to come
to do so. Alternatively, they can begin implementing the E/HRs-based
approach in selected projects and experiment using the new HRs work tools,
at the same time building the capacity of a core team of
trainers/implementers and encouraging senior management to take a lead role.
They also need to make sure they have the capacity and the resources to
implement these principles.

34.Later, NGOs will need to periodically review whether their programs are
reflecting  the E/HRs principles, document how they do deviate from them and
articulate steps to progressively get back to and realize them.

35.Ultimately, the aim is to cede power in NGO programming to the people
they serve, ensuring they are increasingly represented and heard in
program/project decisions.

36.When Northern NGOs become actors in a rights-based framework, they also
need to recognize the existing tensions in their relationship with Southern
partners; these often relate to economic and other inequalities in their
relationship at a time when Northern NGOs are seeking equity. (Beware that,
in HRs work, Southern NGOs are indispensable allies, because they are better
placed to exploit the opportunities and avoid the dangers of HRs advocacy in
their own countries).

37.An additional point for NGOs to ponder is that, in an era of
Globalization, it is not sufficient for them to work exclusively at the
community level. The drivers of poverty and inequity are much more global
than local. Northern NGOs are in a better position to act at the global
level and should do so. Agreement on the agendas for such advocacy work
should be sought with Southern partners.

What will refocusing on E/HRs mean to NGOs working in the health sector?
What is the added value of and the new visibility gained from adopting an
E/HRs-based approach?:

38.Working with an Equity/HRs focus will mean finding gaps in HRs in the
current health work they do; it will mean revising their plans; it will mean
increasing their staff's skills to analyze health from a HRs perspective; it
will mean adopting a 'HRs language' in most of their work; it will mean
focusing more on activities they are not familiar with yet; it will mean
selecting a new set of health priorities (or priorities in health) and
determining whether they do conflict with or complement their existing
priorities and whether they will mean extra work; it will mean reexamining
who their strategic allies are (and which they should take on), as well as
look at their allies' respective roles to find synergies/conflicts/gaps; it
will mean NGOs will also have to increase their resolve to say no to certain
donors; it will mean changing their focus on monitoring and evaluation. And,
last, but not least, it will mean a major repositioning of the NGO's
identity with its various publics and stakeholders.

39.NGOs' HRs advocacy should, from now on, also be internationalized. A
successful example is NOVIB's Social Watch Initiative that watches over the
implementation of governments' commitments taken up and signed on in global
UN meetings; initiatives like this should now be expanded to cover
monitoring E/HRs violations in health and other domains.

40.Operationalizing the E/HRs-based approach therefore requires NGOs to work
at the target group level, work on civil society building, work in
monitoring and influencing government policies, as well as work
internationally. What this challenging agenda means is that without a
political commitment to social equity and HRs, PHC strategies will fail.
This, because poverty erradication strategies cannot ignore the health
status of rights-holders --and that requires addressing unequal power
relations (i.e. analyzing who wants and needs changes in health and who
wants to maintain the status quo).

41.NGOs are, therefore to remain active in structural poverty/ill-health/
malnutrition erradication. Demanding for rights is a battle that has to be
fought in the social and legal arenas, at national, regional and
international level. NGOs cannot do this by just implementing government
commitments and absolving the state of their responsibilities.  The
difficult struggle against the impunity of state-related perpetrators of
violations of HRs has to be undertaken now. NGOs must combine political
action (with a small p) with capacity building and service delivery to
achieve the needed change. Strategies used should not be confined to the use
of legal resources that ignore the political nature of the struggle. (But,
at the same time, beware: NGOs cannot risk creating expectations which, in
the end, they may not be able to fulfill). Governments have simply to be
pushed (using a combination of means) to redefine their responsibilities
towards health.

42.In short, NGOs need to shift from working from a welfare perspective to
an economic justice perspective. The E/HRs-based approach is rather a matter
of commitment than of just another way of approaching the problems of
ill-health and poverty. (SIM 2000) To undergo the shift, NGOs have to take
stock of their social investments so far in social development, as well as
in health and nutrition so as to create themselves a new niche in HRs work
and lobby governments and multilateral agencies alike.

43.To sum up, adopting the Equity/HRs-based approach to health is not a
matter of choice anymore; NGOs have to decide what?, how? and when? This,
since the E/HRs-based approach will become the overall 'best practice' of
the decade...and this is irreversible.

Claudio Schuftan, Ho Chi Minh City
aviva at netnam.vn


[Note of interest:  There are one million NGOs in India; 210,000 in Brasil;
35,000NGOs are operating internationally. All NGOs put together dispense an
estimated 12-15 billion USD per year].

References available upon request.

Acknowledgements:
The preparation of this paper was financially supported by NOVIB (Oxfam
Netherlands).